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at <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Bradley Tisch ❑Zoning Status; CUP: <br /> OWNER ADDRESS (Number,Street.City,State,Zip) Deed Restriction; CSM <br /> 175 Drammen Valley Road Mount Horeb,WI 53572 Variance(# <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (608)523-1163 (608)513-2997 BLTISCH @YAHOO.COM ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) J ❑Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL 044/0506-312-9510-6 A-1(EX) 37.80 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> Perry 3,156 I/4: SE 1/41/4. NW ❑Driveway permits <br /> ADDRESS: (state, county, town) <br /> 175 Drammen Valley Road Mount Horeb, WI 53572 <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Pool J Zoning District <br /> 151 This project is a new building or structure. ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER rEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 0.0 0.0 ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT. 1ST FLOOR: ❑ Erosion Control permit <br /> 1 TOTAL SQUARE FOOTAGE: + (slopes, disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 608.0 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: /-" and available options. <br /> (Please round to nearest dollar) $ 4� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes BINo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes is ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? JYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? QYes ❑No <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes '4No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 4No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ <br /> 545-112(4/08) <br />